Fractures of The Body of The Mandible In Maxillofacial Surgery

INTRODUCTION
01

Introduction
●Owingtoitsprominenceanddistinctionastheonlymobileboneintheface,themandibleisthesecondmostcommon
siteoffacialfractureafterthenose.
●Fractureofthemandibleoccursmorefrequentlythanthatofanyotherfacialskeleton.
●Itistheoneseriousfacialboneinjurythattheaveragepracticingdentalsurgeonmayexpecttoencounter,albeiton
rareoccasions,athissurgery.
●Itisalsoafacialfracturewhichhemayhavethemisfortunetocauseasacomplicationoftoothextraction.

ANATOMY
●Themandibleisaprominenthorseshoe-shapedbone
composedofbilateralverticalandhorizontalunitsanda
centralanteriorunit.
●Theverticalunitsincludethecondylarhead,neck,
subcondylarregion,coronoidprocess,ramus,and
mandibularangle.
●Thehorizontalunitscorrespondtothemandibularbody,
andthecentralanteriorunitconsistsofthesymphyseal
andparasymphysealregions.
●Thecondylearticulateswiththeglenoidfossatoformthe
complexsynovialtemporomandibularjoint(TMJ).
●TheTMJsserveasshockabsorbersthatdissipate
transmittedforces;thus,althoughmorethanhalfof
mandibularfracturesarecomplexandbilateral,the
mandibledoesnotbehavelikeotherringstructuresthat
invariablyfractureintwoplaces.

MUSCULATURE:
JAW ELEVATORS
●Massetermuscle:fromzygomatoangleandramus
●Temporalismuscle:frominfratemporalfossato
coronoidandramus.
●Medialpterygoidmuscle:medialpterygoidplateand
pyramidalprocessintothelowermandible.
JAW DEPRESSORS
●Lateralpterygoidmuscle:lateralpterygoidplateto
condylarneckandTMJcapsule
●Mylohyoidmuscle:Mylohyoidlinetobodyofhyoid
●Digastricmuscle:mastoidnotchtodigastricfossa
●Geniohyoidmuscle:inferiorgenialtubercletoanterior
hyoidbone
Muscles of mastication, which have a displacing influence on mandibular fractures

INNERVATION
Trigeminal Nerve (CN3)
Foramen
Ovale
Mandibular
Foramen
Inferior Alveolar Nerve
Mental Nerve
Mental
Foramen

BLOOD SUPPLY
●Internal Maxillary artery
●Inferior alveolar artery
●Mental artery
●Endosteal blood supply →via inferior dental artery & veins.
●Peripheral blood supply →via Periosteum
●It is important in the healing of fractured bone.

Classifications
Fractures of the mandibular may be classified
according to anatomic location, condition and
position of teeth relative to the fracture, angle
of fracture, or favourableness.

KRUGER’S GENERAL CLASSIFICATION
For the sake of this discussion, the following fracture terms have been
adopted from Dorland’s Illustrated Medical Dictionary:
1.Complicatedorcomplex:Afractureinwhichthereisconsiderableinjurytotheadjacentsoft
tissueoradjacentparts;maybesimpleorcompound.
2.Simpleorclosed:Afracturethatdoesnotproduceawoundopentotheexternalenvironment,
whetheritbethroughtheskin,mucosa,orperiodontalmembrane.
3.Compoundoropen:Afractureinwhichanexternalwound,involvingskin,mucosa,orperiodontal
membrane,communicateswiththebreakinthebone.
4.Comminuted:Afractureinwhichtheboneissplinteredorcrushed.
5.Greenstick:Afractureinwhichonecortexoftheboneisbroken,theothercortexbeingbent.
6.Pathologic:Afractureoccurringfrommildinjurybecauseofpre-existingbonedisease.
7.Multiple:Avarietyinwhichtherearetwoormorelinesoffractureonthesamebonenot
communicatingwithoneanother.
8.Impacted:Afractureinwhichonefragmentisfirmlydrivenintotheother.
9.Atrophic:Aspontaneousfractureresultingfromatrophyofthebone,asinedentulous
mandibles.
10.Indirect:Afractureatapointdistantfromthesiteofinjury.

According to Site
●Depending on site of fracture:
○Dentoalveolar
○Condylar
○Coronoid
○Ramus
○Angle
○Body
○Parasymphysis
○Symphysis
Contemporary Oral and Maxillofacial Surgery 7
th
Edition; Mosby, 2018:
Anatomic distribution of mandibular fractures. (Data from Olson RA, Fonseca RJ, Zeitler
DL,OsbonDB. Fractures of the mandible: a review of 580 cases. J Oral MaxillofacSurg.
1982;40:23.)

According to Angle of Fracture
● An important classification of mandibular angle and body fractures relates to the direction of the fracture line and the effect of muscle action
on the fracture fragments.
● Angle fractures may be classified as:
○Vertically:
a.Favorable
b.Unfavorable
○Horizontally:
a.Favorable
b.Unfavorable.
Vertically Favorable Vertically Unfavorable
Horizontally UnfavorableHorizontally Favorable
● Favorablefracturesarethosewhenthemuscularpullcannot
displacethefracturedpartsandinunfavorablefracturethe
musclepulldisplacestheparts.
● Bodyfracturesoftenareunfavorablebecauseoftheactionsof
themasseter,temporalis,andmedialpterygoidmuscles,which
distracttheproximalsegmentsuperomedially.
● Additionally,themylohyoidmuscleandanteriorbellyofthe
digastricmusclemaycontributetotheunfavorablenatureof
thisfracturebydisplacingthefracturedsegmentposteriorly
andinferiorly.

According to Dentition
●Kazanjian and Converse have classified mandibular fractures by the presence or absence of
serviceable teeth in relation to the line of fracture.
●They thought that their classification will be helpful in determining treatment.
●Three classes were defined:
I.Class I: Teeth are present on both sides of
the fracture line.
II.Class II: Teeth are present on only one side
of the fracture line.
III.Class III: The patient is edentulous.

Fracture of Body of Mandible occurs between the distal symphysis
to a line coinciding with the alveolar border of the masseter muscle
(usually including the third molar).

HISTORY
02

Take AMPLE History
●A -Allergies
●M -Medications (Anticoagulants, insulin and cardiovascular medications
especially)
●P –Previous medical/surgical history
●L –Last meal (time)
●E –Events/Environment surrounding the injury (Exactly what happened)
●Howdid the accident occur?
●When did the accident occur? Time since injury.
●Whatare the specifics of the injury, including
●the type of object contacted, the direction from which contact was made?
●Did loss of consciousness, vomiting, bleeding occur?
●What symptoms are now being experienced by the patient, including pain, altered
sensation, visual changes, and change in bite?

oKnowledgeofthetypeanddirectionofthecausativetraumaticforcehelpsindeterminingthenatureofinjury.
oForexample,motorvehicleaccidents(MVAs)havealargerassociatedmagnitudeofforcethanassaults.
oAsaresult,apatientwhohasexperiencedanMVAmostoftensustainsmultiple,compound,comminutedmandibular
fractures,whereasapatienthitbyafistmaysustainasingle,simple,nondisplacedfracture.
oKnowingthedirectionofforceandtheobjectassociatedwiththefracturealsoassiststheclinicianindiagnosingadditional
fractures.
History
oObtain a thorough history specific to pre-existing conditionssuchas:
Temporomandibular Joint
(TMJ) DysfunctionSystemic Bone Disease
Neoplasia
Arthritis
Collagen Vascular
Disorders

PRESENTATION
03

Indications of the Presence of Mandibular Body Fracture
Symptoms
(Subjective )
●Pain
●Malocclusion
●Numbness of lower lip
●Bleeding
●Swelling
●Tenderness
●Mobility
Signs (Objective)
1.Deformity:Externaldeformityisoftendifficulttoseeclinicallyduetoswelling.Intraoralexammayshowdisplacementcreatinga
stepdeformity.Changeinfacialcontourorlossofexternalmandibularformmayindicatemandibularfracture.Abodyfracturemay
causethelateralaspectofthefacetoappearflattened.Lossofthemandibularbodyonpalpationmaybeduetoanunfavorable
fracture.Theanteriorfacemaybedisplacedforward,causingelongation.Inthiscase,theanteriormandibleisdisplaceddownward.
2.Pain:Fracturesitesaretendertopalpationandsometimestocompression.
3.ToothandBoneFragmentHypermobility:(espiffracturebody+dentoalveolar)Toothandbonefragmenthypermobilityare
signsofmandibularfracture.
4.Lacerations,Bleeding,Hematoma,Ecchymosis,andSwelling:Tearingoftheperiosteumandmusclesattachedtothe
mandiblecancausesignificantbleeding,producingvisiblehemorrhage,sublingualhematoma,swelling,andlife-threateningairway
compromise.Urgentintubation,andinfrequentlytracheostomy,mayberequiredtomaintainrespiration.Lacerationsmayprovide
diagnosticevidenceofthetypeoffracturesustained.Hematomaandecchymosismayalertthecliniciantoamandibularfracture.
Donotclosefaciallacerationsbeforetreatingunderlyingfractures.Ecchymosisinthefloorofthemouthisadiagnosticsignofa
mandibularbodyorsymphysisfracture.
5.SensoryDisturbances:Theinferioralveolarnerve(V3)coursesthroughthemandibularbodyandangle.Fracturesofthebony
canalcancausetemporaryorpermanentanesthesiaofthelip,teeth,andgingiva.Mostnondisplacedmandiblefracturesarenot
associatedwithchangesinlowerlipsensation;however,displacedfracturesdistaltothemandibularforamen(inthedistributionof
theinferioralveolarnerve)mayexhibitthesefindings.Thelingualnerve(V3)liesclosetothelingualcortexnearthemandibular
thirdmolar.Injurymaycausetemporaryorpermanentanesthesiatotheipsilateraltongueandgingiva.
Pain,swelling,redness,and
localizedheataresignsof
inflammationevidentin
primarytrauma.

EXAMINATION
04

General Clinical Examination

Primary Survey: ABCDE
●Airway maintenance with cervical spine
control
●Breathing and adequate ventilation
●Circulation with control of haemorrhage
●Degree of consciousness
●Exposure of the patient via complete
undressing to avoid overlooking injuries
●camouflaged by clothing

Examination
General Clinical Examination:
●Airway, respiration, fluid resuscitation, and control of hemorrhage.
●C-spine injury (films must include CI-C2 and C6-C7. If not able to be visualized,
the patient must be assumed to have a C-spine fracture and should have a
cervical collar, and movement of the head should be restricted).
●Upright chest x-ray (pneumothorax, hemothorax, ruptured thoracic aorta, rib
fractures, pulmonary contusion, and aspiration).
●Head injury
○A. Glasgow coma scale is evaluated and consists of:
○B. CTscan.
○C. Intracranial pressure monitor, if comatose, or coma scale less than 15 if general anesthesia
is to be used.
●Abdominal injury (peritoneal lavage).
●Extremity injury, pelvic injury (appropriate x-rays should be routine to detect
occult fractures).

Local Clinical Examination
Mandible is palpated for any:
•Change in facial contour and mandibular arch form
•Loose teeth and crepitation on palpation
•Tenderness
•Step Deformity
Test For:
•Anesthesia, Paresthesiaor Dysesthesia of lower lip
•Abnormal mandibular movements
•Change in occlusion
Check For:
•Laceration, Hematoma and Ecchymosis
•Swelling
•FacialDeformity/Asymmetry
•Drooling

RADIOGRAPHS
05

Possible Extra-Oral Radiographs:
●CT & CBCT Scans
○ CT: In patients with multiple traumatic injuries, imaging of the face, orbits, and mandible can be easily incorporated into contrastmaterial–enhanced
whole-body CT protocols, or it may be performed with nonenhanced CT of the cervical spine in cases of low-impact trauma.
○ CBCT: The same volume visualization techniques used in CT are easily applied with less radiation dose and being more cost-effective than CT. The
greatest limitation of CBCT is poor soft-tissue contrast.
●OPG
○ Theveryinformativeastheentiremandibleisviewableinasingleplanealongwithvariousadvantagessuchassimplicityoftechnique,cost-
effectiveness,andlowradiationexposurecomparedwithCTorcone-beamcomputedtomography(CBCT)
●Plain Radiography
1. Left-Right Lateral Oblique Extra-oral Radiograph
2. Posteroanterior Extra-oral Radiograph
• Traditional View
• Caldwell View
3. Towne’s View Anteroposterior Extra-oral Radiograph
Most Informative
Possible Intra-Oral Radiographs:
●Mandibular Occlusal and Oblique Occlusal Intra-oral Radiograph
●Intra-oral Periapical Radiographs

A
B
Imagesobtainedina51-year-oldmanwhounderwentORIFofamandibularbody
fracture.TheMMFwasleftinplace,butthepatientreportedlyforgottoundergoafollow-
upexamination.(A)AxialCTimageshowsabonesequestrum(arrow)intheleftbodyand
parasymphysisregion,witharoundedsclerotic-appearingleftmandibularbody.Free-
floatingscrewsfromfailedhardwarearepartiallyvisualizednearthesequestrum.(B)
VolumerenderedCTimageafterdebridementofthedevitalizedboneandinfectedsoft
tissueshowstheexternalfixatorplacedforstagedintervention.
CT
3D Rendered Images of Fracture of Mandible
CBCT
CT & CBCT Scans

Orthopantogram
Panoramic x ray showing a simple fracture of the body of the mandible.

Left & Right Lateral Oblique Xray
The left lateral oblique view image demonstrates a fracture of the body
of the mandible.
The right oblique view image demonstrates no displaced fracture.

Posteroanterior Xray
Traditional PA view of a fracture of the left body and angle.
Caldwell PA view of a left body and angle fracture.

Towne’s View Xray
Towne radiographic view of a left body and angle fracture.

Intra-oral Radiographs
Mandibular occlusal Intra-oral radiograph showing
pathological fracture of body of mandible due to
osteomyelitis.
Periapical film showing fracture of body of mandible and
tooth relationship to the fracture line.

Magnetic resonance imaging (MRI) is better for evaluating soft-tissue
disease, such as hematoma and complications of trauma.

MANAGMENT
06

Basic Principles in Management
Preservation of Life
1.Airway maintenance
2.Bleeding control
3.Consciousness restoration and circulation maintenance
Maintenance of Function
Followingthebasicprinciplesoffracture
management,basicreductionandocclusal
maintenance.
Esthetic Restoration
EstheticRestorationisachievedbyplastic
surgeriesandotherestheticsurgeries.
01
02
03

Goals of Mandibular Body Fracture Repair:
✓Re-establish a stable occlusion
✓Re-establish an adequate range of motion
✓Restore facial and mandibular arch form
✓Restore pain-free function
✓Avoid growth disturbances of the mandible
The principle/method for the treatment of facial fracture to be followed in a specific case
depends on:
✓Fracture pattern
✓Skill of operator
✓Resources available
✓General medical conditions of patient
✓Presence of other injuries
✓Degree of infection
✓Associated soft tissue injury and loss

Principles of Management of Fracture
Reduction Fixation

Reduction
●Definition:It is theprocedure that involves bringing the fractured fragments close to each other and in the correct
anatomic and functional position.
●This can be done either by a closed/nonsurgical way or by a open/surgical way as the condition demands.
I.Closed/Non Surgical Reduction:
•Mostlydonebyocclusalmaintenance.
•Thewearfacetsactsasanimportantcluefortheocclusionanterioror
lateralopenbite.
•Temporaryreductionisdoneinsomecasetopostponethesurgical
proceduretillthegeneralhealthofthepatientimproves.
•Non-surgicalreductionisdoneeitherbyusingspeciallydesigned
forceps-Rowe’sdisimpactionforceps,inarockingandrotating
movementorbyusingelastictractionalforcesorevenmanually.
Methods:
1.Archbars
2.DentalWiring(directwiringoreyelet)
3.PlacementintoIntermaxillaryfixation(IMF)
4.Gunning'ssplint
II. Open/Surgical Reduction:
•Thisisdoneincaseswhereclosedreductionisnot
effective.
•Varioussurgicalapproachesarefollowedtoreachthe
siteoffracture.
Methods:
1.Internalwirefixation
2.BonePlates
3.BoneClamps
4.ExternalFixation
Frame of fracture reduction
(Outer to inner)
❖Reductionshouldbedonefromoutsidetoinside.Theouterframebonesarereducedfirstand
theinnernasalbonesatthelast

Tooth In Fracture Line
● Before reduction any teeth present in the fracture line may require extraction.
Indications for removal of teeth in the line of fracture
1.Toothluxatedfromitssocketand/orinterferingwithreductionofthefracture.
2.Tooththatisfractured.
3.Toothwithadvanceddentalcariescarryingasignificantriskofabscessduring
treatment.
4.Toothwithadvancedperiodontaldiseasewithmobilitywhichwouldnotcontribute
toestablishmentofstableocclusion.
5.Toothwithexistingpathologysuchascystformationorpericoronitis.
Indicationstoleaveteethinthelineoffracture
1.Tooththatdoesnotinterferewithreductionandfixationoffracture.
2.Iftoothremovalrequiresremovalofexcessiveamountofbonesoasto
compromisethefracturesiteanpossibleplate/screwfixation.
3.ooththatisingoodconditionandassistsinestablishingocclusionandreducing
thefracture.

Immobilization:
● Immobilization is the process of fixation or making the fractured fragments stay in their reduced, anatomical and functional position until healing
occurs.
● Various methods of immobilization are:
I. Osteosynthesis without intermaxillary fixation:
a.Non-compression plates
b.Compression plates
c.Miniplates
d.Lag screws
e.Resorbable plates and screws
II.Intermaxillary fixation:
a.Bonded brackets
b.Dental wiring
i. direct
ii.eyelet
c.c. Arch bars (Winter, Jelenko, Erich type)
d.d. Cap splints (used in children)
e.GunningSplint
III.Intermaxillary fixation with osteosynthesis:
a. Transosseous wiring
b. Circumferential wiring and internal suspension
c. External fixation
d. Transfixationwith Kirschner wires

Intraoral
Incision

PRINCIPLES
Vestibular Incisions
● The intraoral approach is the usual access for simple fractures of the
body, symphysis, and angular regions.
●The approach can be extended posteriorly (dashed line) for better
access to the body, angle and ramus regions.
● Restricted access and contamination:
○ Incomplexfracturesincludingcomminuted,edentulous,andavulsive
fracturesrequiringtheplacementofload-bearingreconstruction
plates,atransfacialapproachmayprovidebetteraccess.
○ Oralcontaminationisnotacontraindicationforanintraoralincision.
●Neurovascular structures
○ Whentheincisionisextendedposteriortothecanineteeth,the
mentalnervecanbedamaged.Keeptheincisionsuperiortothe
mentalnerveinthebodyregion.
○ Particularlyintheextendedtransoralapproach,caremustbetakento
protectthementalnerveintheanteriorbodyregion.

Mucosal Incision
● Unlesscontraindicated,infiltratetheareawithalocalanestheticcontaininga
vasoconstrictor.
● Makeanincisionthroughthemucosainthevestibule.
● Betweenthecaninestheincisionismade10–15mmawayfromtheattachedgingivaina
curvilinearfashion.
● Posteriortothecaninetheincisionisonly5mmawayfromtheattachedgingiva,staying
superiortothementalnerve.
Surgical Flap Dissection
● Carrytheincisionthroughthemucosallayerintheanteriorregionoutinthelipawayfrom
vestibularfold.
● Dissectamucosalflapthatretractsorislifted(asshown)toexposethesurfaceofthe
mentalismuscle.
● Thebranchesofthementalnervearelocatedjustunderneaththemucosalflapandmust
berespected.
Mentalis Muscle Dissection
● Thementalismuscleisincisednearthealveolarboneridgethuscreatingastepwise
approachwhichprotectsthementalnerve.
● Later,duringwoundclosurethementalismuscleshouldbeproperlyreattached

Lateral/Posterior Vestibular Incision
●Theapproachcanbeextendedlaterallyandposteriorlytoprovideaccesstothebody,
angleandramusregionsofthemandible.
●Right-angledretractorsarehelpfulinthisapproach.
●Extendtheapproachlaterallyandposteriorly
Dissection of The Mental Nerve
● Intheextendedintraoralapproach,caremustbetakentoprotectthetrunkofthe
mentalnervewhichexitsintheanteriorbodyregion.
● Keeptheincisionsuperiortothementalnervetrunk.
● Dissectthementalnerve
Pearl:freeingofthementalnerve(skeletonization)
● Freeingofthementalnerveallowsforbettersoft-tissueretraction.
● Tissuescissorsareusedtospreadparalleltothenerve.
● Scalpelscouldbeusedbutattheriskofinjuringthenerve.

Combination with The Transbuccal Technique
● Toplaceposteriorscrewsminimizingmentalnerveretraction,thetransbuccal
trocarmayassistthesurgeonandkeepthescrewsperpendiculartotheplate.
Wound Closure
● Afterthoroughlyirrigatingthewoundandcheckingforhemostasistheincisionis
closed.Anteriorly,thementalismuscleisreapproximatedtopreventdroopingof
thechintissues.
● Themucosaisclosedwithinterruptedorrunningresorbablesutures.
● Anelasticpressuredressingonthechinregionhelpssupportthesofttissuesand
preventhematomaformation.

Transbuccal
System

PRINCIPLES
General Considerations
Transbuccalinstrumentationextendstheversatilityoftransoralapproaches.Inadditiontothe
transoralexposurethesofttissuesoverlayingtheposteriordivisionsofthemandiblearepiercedfrom
externally.Viathistransbuccalrouteaspecialinstrumentationisinserted:theso-calledtransbuccal
handlewithcannula.Throughthecannula,drillingandscrewinsertionbecomespossibleataright
angletothelateralmandibularsurface.Controlandguidanceoftheprocedureisdonesimultaneously
fromtheexternalsideandtheinternalapproach.Intheclinicalsituation(contrastingincontrastto
thisillustration)thesofttissuesarelessretracted.
Resiliency
Thesoft-tissueresiliencyofthecheekisthekeyforshiftingthetransbuccalcannulatotheintended
screwinsertionsite.Asaprinciplethecannulaisbestmovableifitisinsertedatthemaximal
transverseextensionofthewoundcavity.Movementsarelimitedapproachingthebordersofthe
cavitybeingreducedalongconcentriclinesaroundthesoft-tissuechannel.Thedissectioncavity
alongthelateralsurfaceofthemandibleisreducedinitstransversespacingtowardstheposterior
borderoftheramusandtowardsthementalforamen.
Beawarethatifthecannulaisinsertedinthevicinityofthementalforamen,theneurovascularbundle
caneasilybestretchedordamagedbybriskmovementsofthetransbuccalhandle.Usually,thezone
nexttotheneurovascularmentalbundleispreferablyreachedtransorally.
Incaseofplacingseveralscrewsatatime,eg,forapplicationofalongerosteosynthesisplate,itmay
beadvantageoustouseseveraltransbuccalchannels.Thisprovidesaperpendicularinsertionofthe
drillbitandscrewdriver.Tousethefullspaceofthedissectioncavitytheretractorshouldbe
mountedatashortdistancetothetipofthecannula.

Drill Sleeves
● For an exact drilling procedure, a set of exchangeable drill sleeves is available according
to the different diameters of the drill bits.
● Some drill sleeves offer the possibility to connect a plate to its tip, thus facilitating plate
positioning.
● The side windows in some of the drill sleeves allow for depth control during drilling or
screw insertion and for direct irrigation
Transbuccal Guide
Themaincomponentofthetransbuccalsystemis
thehandle,equippedwitheitheranattached(as
illustrated)orfixedcannula.Thetrocar(alsoknown
asobturator)isusedtopenetratethesofttissues
withapointedtip.
Mountable Retractors
Throughthetransoralroutethecannulaismountedwithaself-holdingretractorforthebuccalsoft
tissues.Thereareseveralretractortypesavailableuseddependingonthepreferenceofthesurgeon.
Retractor Types:
a. Ring shaped retractor (fixed with a screw to the cannula shaft)
b. Blade retractor (fixed with a screw to the cannula shaft)
c. Forceps retractor (fixed to the cannula shaft)
d. U-shaped retractor (fixed externally to the handle)

Insertion of Transbuccal Instrument
Make stab incision
Makeasmallstabincisiontoprepareforthe
insertionofthecannula.Thelocationis
predeterminedbypalpation.Theindexfingeris
placedoverthedesiredosteosynthesissiteand
matchedwiththethumbonthecheeksurface
andmarked.
Theorientationofthescalpelblademustbe
paralleltotherelaxedskintensionlines(RSTL).
Insert the cannula with trocar through the facial
tissue down to the bone.
Remove the trocar to open the cannula as a
channel for the screw insertion procedure.

Screw Insertion
Insert Drill Guide
Nextanappropriatedrillguideischosenand
insertedintothecannula.Thescrewinsertionis
demonstratedusingtheringcheekretractor.
Drill Hole
Thetipofthecannulacontainingthedrillguideisplaced
exactlyattheintendedscrewpositiondirectlyonthebony
surfaceorontotheholeofanosteosynthesisplate.Drillahole
usingtheappropriatedrillguideanddrillbit.Theadvancement
ofthedrillbitintothebonecannotbedirectlyobservedunless
adrillsleevewithwindowisusedorthecannulaisretracted
slightlyshowingtheexitingdrillbit.
Determine Screw Length
The appropriate screw length is
determined with a depth gauge and the
screw is inserted using a self-holding
screwdriver.
Note: the drill guide must be removed
before the depth gauge is inserted.
1
2 3
4
Screw Insertion
Theself-retainingscrewdriverwiththescrewmountedonthetipofitsbladeisintroducedintothecannula
strictlyintheaxisofthecannulahole.Ifitisslantedthescrewcaneasilybelostfromthescrewdriverblade.
Afterthefirstturnstotightenthescrew,thecannulacanbeslightlyretractedtoobservethefurtherprogressof
screwinsertion.
Thetransbuccalsystemisdismantledafterallscrewshavebeenplaced.

Submandibular
Incision

Principles
● Thisapproachisselectedforfracturesofthemandibularbodyandangleregions
unsuitableforintraoraltreatment.
● Thisappliestomoredifficultfracturepatternssuchascomminuted,atrophic,
anddefectfracturesinordertoallowoptimalmanipulationofthefragments,
goodcontrolofthelingualcortexandinferiorborder,andtheapplicationofthe
selectedhardware.
Variations
● Theincisioncaneitherbeparalleltotheinferiorborderofthemandible(A)orbe
placedinanexistingskincrease(B)formaximumcosmeticbenefit.
Ifusingskincreasesfortheincision,the
orientationofthescalpelbladeisparallelto
therelaxedskintensionlines(RSTL).
Neurovascular structures
Themainneuralstructureisthe
marginalmandibularbranchofthe
facialnerve(CNVII).Thefacial
arteryandveinarealsoencountered
duringthisdissection.

Skin Incision
General Consideration
●Useofasolutioncontainingvasoconstrictorsensureshemostasisatthesurgicalsite.Thetwooptionscurrently
availablearetheuseoflocalanestheticoraphysiologicsolutionwithvasoconstrictoralone.
●Useofalocalanestheticcontainingavasoconstrictormayimpairthefunctionofthemarginalmandibularnerveand
preventtheuseofanervestimulatorduringthesurgicalprocedure.Therefore,considerationshouldbegiventousing
aphysiologicalsolutionwithvasoconstrictoraloneorinjectingthelocalanestheticwithvasoconstrictorinavery
superficialmanner.
•Thelengthofthe
incisiondependson
fractureextendand
theplannedinternal
fixationtechnique.
•Diagramshowsaskin
incision2-3cmbelow
theinferiorborderof
themandible.
Incision of skin and subcutaneous tissues
exposes the underlying platysma muscle.

Dissection
oInordertoprotectthemarginalmandibularbranchofthenerve,theplatysmais
underminedbluntlywithscissorspriortodividingitwithascalpel.
oTheplatysmamuscleisdividedsharply,preferably2-3cmbelowthemandibularborder,
notnecessarilyatthesameleveloftheskinincision.
o Superiorsubplatysmaldissectionwouldexposetheunderlyingmarginalmandibular
branchofthefacialnerve(CNVII).Thisisnotusuallynecessary.
o Byligatinganddividingthefacialarteryandveinandthenretractingthevessels
superiorly,themarginalmandibularbranchofthefacialnerveremainsincludedinthe
superiorflapandisthusprotected.

Exposure
Dividethepterygomasseteric
slingandincisetheperiosteumat
theinferiorbordertoexposethe
fracturesite.
Expose the body and
angle region.
Wound Closure
For wound closure, the pterygomassetericsling is
closed.
Thewoundisclosedinlayerstorealigntheanatomic
structuresandeliminatedeadspace.Theplatysma
muscleisclosed.Avarietyofskinclosuretechniques
areavailablebasedonsurgicalpreference.Adrain
maybeusedifnecessary.

Simple Mandibular
Body Fracture
Management

OBSERVATION
Principle
The patient is assessed clinically at regular intervals by monitoring the occlusion radiographically to assure that union occurs andthe
fracture does not displace
Main Indications
○Seldom indicated for non-mobile non-displaced fractures with undisturbed occlusion.
Further Indication
○When fracture topography and muscular forces (favorablefracture) allow a stable environment of undisturbed healing
Requirements
○Fully compliant individual who is willing to adhere to a non-chew diet and avoid physical exercise and sports for a period of
6 weeks
○ Patient must be advised that additional treatment may be required if complications arise during the observation period
Not a Favorable Technique
1

CLOSED REDUCTION
●Fracture reduction that involves techniques of not opening the skin or mucosa covering the fracture site
●Fracture site heals by secondary bone healing
“If the principle of using the simplest method to achieve optimal results is to be followed, the use of closed reduction for
mandibular fractures should be widely used” Peterson’s Principle of Oral and Maxillofacial Surgery 2
nd
edition
Main Indications
○Non-or minimally displaced simple fractures in compliant patients with good dentition amenable to MMF.
Further Indications
○ Premorbid or unstable medical condition preventing general anesthetic
○ Conditions making open reduction and internal fixation difficult
○ Patient refusal of operative treatment
○ Unavailability of plates and screws
Special Consideration
○MMF may be contraindicated in patients with psychiatric disorders, seizure disorders, and alcoholics.
2

● Circumdentalwiringissometimesusefulforprovisionalfracture
reduction.
● Applyarchbarstothemandibleandmaxilla.Sometimes,noteverywire
inthoseteethadjacenttothefracturehastobefullytightenedbefore
manualfracturereductionisaccomplished.
● Applytheintermaxillaryligaturestomaintaintheocclusalposition.
●ThepatientisusuallymaintainedinMMFnomorethan6weeks.
2
● Pearl:individuallaboratorydesigned
archbars
● Aftertakingimpressionsindividual
archbarscanbefabricatedondental
casts.Priortothearchbarfabrication,
thesecastsaresectionedandthe
fractureisreduced(seebluezoneon
thecast).Thus,thearchbarhelpsin
thereduction.Furthermore,individual
archbarspreventdamageofthe
periodontalsofttissuesandareless
invasive.
● Closedtreatmentforsimplefractures
ofthebody
Clinical image shows the preshapedarch bar before applying MMF.

ORIF: One Miniplate
Principles:
● Theideallineofosteosynthesisinthebodyregionrunsattheverticalheightofthe
toothapicesfromthecanineregiontotheobliqueline.Thiscarriesintotheoblique
ridgewhichturnsintotheanteriorouterrimoftheramus.
● Thislineislocateddirectlyunderneaththemucogingivalsulcusthatcanbeexposed
withease.Thebonethicknessofthelateralcortexvariesbetween6and8mm
approximately.Toavoidinjuryofthetoothroots,monocorticalscrewslessthan6mm
longshouldbeusedforplatefixationalongthissectionoftheidealosteosynthesis
line.
● Thissingleplatefixationmethodiscontraindicatedintheanteriormandibularbody
becauseoftheexistingrotationalforcesinthatareathathavetobeneutralized.Two
miniplatesshouldbeappliedtoneutralizethoseforces.
● Intheposteriortransitiontotheangleandramus,asecondplatejustbelowtheoblique
ridgemaybeadvantageousincaseofreducedbonestock(eg,animpactedwisdom
tooth)orsignificantfracturedisplacement.
Main indications
● Simplefracturesincompliantpatientswithgooddentitionandbuttressingofthe
segmentsafterreduction.
3

Selection of Approach
These fractures can often be approached and treated
through the intraoral approach.
However, depending on the difficulty or severity of the fracture, and/or
the presence of a laceration suitable, an extraoral approach via the
submandibular route may be indicated.
3

Reduction
MMF
Intheisolatedmandiblebodyfracture,preferably,anarchbarisappliedforMMF.Thearch
barprovidesadditionalstabilitybytensionbanding.Thisequatestoasecondlineof
resistanceinparticularwithbitingloadanteriortothefractureline.Thearchbarshould
includeatleastallteethintheaffectedquadrantofthejaw.Itisnotnecessarytoencompass
thewholedentalarch.
MMFbonescrewsprovidetemporaryfixationonlyduringsurgeryanddonotcontribute
postoperativelytostabilization.
ManualReduction
Reductionisdonemanually.Sincetheindicationforsingleminiplatefixationislimitedonly
tominimallydisplacedfractures,therewillbenomajordiscrepanciestobeovercome.
Themaintenanceofthereductionwithaconventionalclampbecomesmoredifficultthe
furtherposteriorthefractureislocated.Theclampscanbeappliedintotinypredrilledholes
intheoutercortexthatdonotinterferewithlaterplateplacement.
3

Fixation
Choice of Implant
● A variety of implants can be used. In the original Champyversion a 4-hole
miniplate without centerspace was used.
● Today, the same type of plate is still applicable. The following alternatives
provide similar or incrementally higher stability:
● 4-or 6-hole mandible plate 2.0 with or without centerspace
● 4-or 6-hole small profile locking plates 2.0
● 4-or 6-hole medium profile locking plates 2.0
● The plate of greater strength is used for additional stability and safety.
3
Plate contouring
● Contour the plate according to the surface anatomy adjacent to the fracture
line on both sides using bending pliers. Longer adaptation plates should be
bent starting at one end and successively proceeding towards the other end.
Intermediate steps can be checked on the bony surface for correct seating.
● Finally check the plate for precise fitting in-situ.

Fixation
Drill first screw hole
● Hold the plate with an appropriate instrument (eg, periosteal elevator or
forceps).
● Use a 1.5 mm drill bit with 6 mm stop to drill monocorticallythrough the plate
hole next to the fracture line in the anterior fragment.
●The surgeon must be aware that a cortical plate may be very thin in this
region and damage to the tooth roots is still possible even when using a 6
mm drill bit with stop.
3
Insert Screw
● Insert a 2.0 mm screw, 6 mm in length. Do not fully tighten it until the final
reduction and plate position are confirmed.
● Finally check the plate for precise fitting in-situ.

Fixation
Insert second screw
●Insert a second screw in the hole next to the fracture line in the posterior
fragment. The periosteal elevator is used now to keep the far end of the plate
at the correct vertical level.
● Tighten both screws.
● The clamp can be removed afterwards.
3
Additional Screw Placement
● Fill the remaining plate holes with screws in an orderly fashion continuing
from the plate holes next to the fracture to the outer plate holes.

Fixation
Confirmation of Reduction
●Asplayingoftheinferiorborderofthemandiblecanberuled
outbyfurthersoft-tissueexposureintraoperatively.In
minimallydisplacedfracturesthisshouldnotbenecessary.
● Priortowoundclosureconfirmadequatereductionalongthe
exposedfractureline.Thefracturealignmentatthelower
bordercanbepalpatedgivingindicationofmajorgapping.
● Furthermore,acontrolofthefracturelineintransverseplane
ispossibleonlyindirectlybycheckingtheocclusionand
articulation.Priortothis,theMMFligaturesmustbe
removed.
3

ORIF: Lag Screws
Principles:
● Lagscrewfixationusesstabilizationbycompressionthatreliesonthebonybuttressingofthefracturetohelpstability.
● Onereasonwhythemandibularbodyiswellsuitedtolagscrewfixationisthethicknessofthebonycorticeswhich
provideextremelysecurefixationwhenthescrewsareproperlyinserted,providinginterfragmentarycompression.
Zonesforscrewplacementinthemandibularbody
● Therearetwointrabonestructuresthatmustnotbeharmedbyscrewinsertion:themandibularcanalandthetooth
roots.
Danger zone –“no mans land”
● The classical description for screw placement in plate and screw osteosynthesis is depicted for orientation.
Monocorticalscrews can be inserted above the level of the mandibular canal. The use of bicorticalscrews is restricted to
the area below the course of the nerve canal at the level of the lower mandibular border.
4
MainIndications
● Sagittal/obliquefractures
Advantagesofthelagscrewsoverplatefixationsare:
● Rapidapplicationwithahighlevelofstability
● Idealfracturealignmentandinterfragmentary
buttressing
● Intraosseouslocationavoidingpalpability
● Lessfixationhardwareresultinginlowercost
Disadvantagesare:
• Technicallydemanding
•Difficultimplantremoval(ifneeded)
•Lagscrewscanhardlybeusedintransversefractures
ofthebody.

Variationsofmandibularcanalandalveolar
•Theremaybevariationsofthecourseofthemandibularcanalandthealveolar
nerve.Thestandardsituationisdepictedinthepreviousstep,buttheverticalheight
ofthecanalcanbelocatednexttolowerborderofthemandible(asillustratedhere).
•Thealveolarnerveitselfcanconsistofasinglebundleinsidethecanalbutitcan
alsospreadinaplexusformationinsidetheoverallbonycross-sectionofthe
mandible.Thesesituationspreventtheusualscrewinsertionandrequirean
individualscrewand/orplateplacement.
4
Screw insertion can be done in a serial
pattern at the lower border of the mandible.
ScrewInsertionPattern
•Alternatively,screwscanbeplacedinatripodfashion
usingthelowerandtheupperinsertionzone.Inthe
upperzone,theanatomicrelationbetweenthenerve
canalandthetoothapicesvaries.Sometimesthereis
nospacebetweenthetoothapicesandthenerve,which
isaclearcontraindicationtofollowthispattern.
•Usingthelagscrewsinatripodfashionprovides
additionalstability.Notehowthesuperiorscrewavoids
boththedentalrootsandthealveolarnerveinthe
illustration.
Numberofscrews
•Inordertowithstandrotationalforcesaminimumoftwoscrewsisrequired.Foradditional
stabilityitisrecommendedtouseatleastthreescrewsespeciallyif2.0mmscrewsareapplied.

4
Reduction
Selection of approach
These fractures can often be approached and treated through the intraoral approach.
However, depending on the difficulty or severity of the fracture, and/or the presence of a laceration suitable, an extraoral approach via the
submandibular route may be indicated
Clamp Application
•InafirststepthepatientisplacedintoMMF.Thebonyfragmentsarethenreducedmanually.
•Afixationclampcanbeappliedtomaintainthereduction.Therefore,atowelclampmaybeused
transcutaneouslytokeepthereductionatthelowerborderwiththeprongscominginfromthemedial
sideandlaterally.Usually,thereshouldbenoriskofinjuringthemarginalmandibularbranchofthefacial
nerve.Theaccessibilitytothelowerbordermaybecompromisedbythetowelclamp.
Withalargedimensionreductionforcepsitispossibleto
prefixthelateralfragmentinasagittalfracture
configurationtothecontralateraloutercortex.Onthe
contralateralcortextheprongisappliedtransmucosally.
Alternative: MMF
•AnothermethodtomaintainthereductionistheuseofMMF
screws.Theymustbeappliedmonocorticallyintheposterior
fragment.Allscrewsinthelowerjawmustbeintegratedintoan
appropriatecerclagewiththemaxillarycounterparttokeepthe
fragmentsaligned.Theposteriorfragmentshouldhavetraction
totheanteriormaxillaandviceversa.
•Inthiscaseanarchbarisnotsuitedforreductionofthe
fragments.Itcanfixonlyoneofthefragmentsviatheteeth.
Thiswillusuallybethelargeranteriorfragment.

4
Fixation
General Consideration
Theverticalangulationofthescrewshouldbe
variedasfaraspossibletomeetthebevelof
thefractureat90°andtoprovidean
uninterruptedapproximationoftheinnerand
outerfragmentduringthecompression
process..
Alternative: Transbuccal System
Theuseofthetransbuccalsystemmay
becomenecessaryinthedorsalcaudal
regionofthemandibularbody,whichis
inaccessibletransorallywithascrewdriver.
Maximalstabilitybetweenthefragmentsis
achievedbycompressingtherough
surfacesofthefractureinterfaceasityields
maximumfrictionaleffect.Acrucialpointis
thechoiceoftheappropriatescrewlength
sothatthefartipofthescrewfullyengages
thefarcortexwiththescrewtipexiting
slightlyabovethebonysurface.
The MMF is now released. A control of the final
reduction is hardly possible by clinical assessment.
Only the anterior outer fracture line can be checked
for accurate alignment. The internal bony situation
will only be deduced from the general control of the
occlusion and articulation. The anatomic reduction
can only be assessed postoperatively with 3-D
imaging techniques. Illustration shows the completed
osteosynthesis with fully inserted bicorticalscrews.
Completed
Osteosynthesis

ORIF: Two Plates
Principles:
Platelocation
● Thesuperiorborderplateispositionedontheideallineofosteosynthesis.
● Theinferiorborderplateislocatedatthebaseofthemandibularbodyinalongitudinalfieldbelowthecourseofthe
mandibularcanal.
Ideal line of osteosynthesis
Theideallineofosteosynthesisinthebodyregionrunsattheverticalheightofthetoothapicesfromthecanineregionto
theobliqueline.Thiscarriesintotheobliqueridgewhichturnsintotheanteriorouterrimoftheramus.
AccordingtoChampy,inthetransitiontothesymphysis(anteriormandibularbody)theinsertionoftwoplatesalongthe
upperandlowerborderofthemandibleismandatorybecausetheremayberotationalforcesthathavetobeneutralized.
Intheposteriortransitiontotheangleandramusasecondplatejustbelowtheobliqueridgemaybeadvantageousina
reducedbonestockduetoanimpactedwisdomtoothorinmajordislocation.
Biomechanics
● All biomechanical models developed to date have shown that two points of fixation (ie, two plates) provide much
more stability than a single plate. Therefore, when more stability is deemed necessary the addition of a second
plate provides more rigidity.
Sequence of plate insertion
● The superior plate is inserted first in order to achieve preliminary fixation. This will prevent inadvertent
displacement of the fragments during subsequent contouring and the insertion of the inferior border plate.
5
Main Indications
● Simplefracturesintransitionalareasofthemandibularbody.

Surgical Approach
● Theaccessibilityoftheinferiorborderofthemandibleviaanintraoralapproachdecreasesfromtheanteriortothe
posteriorbodyregion.
● Intheposteriorareaatransbuccalapproachwillbenecessaryatleastforscrewinsertionintotheposteriorplate
holes.
● However,dependingonthedifficultyorseverityofthefracture,and/orthepresenceofalacerationsuitable,an
extraoralapproachviathesubmandibularroutemaybeindicated.
Choice of Implant
Superior border plate
● The superior border is treated with a tension band plate with monocorticalscrew fixation. The profile of
this plate can be minimal.
● The plate selection can be as follows:
○4-or 6-hole mandible plate 2.0 with or without centerspace
○4-or 6-hole small profile locking plate 2.0 with or without centerspace
Inferior border plate
● The profile and type of the inferior border plate can range from a conventional miniplate to locking plates of
incremental size, large sized fracture plates to reconstruction plates.
● For simple fractures, the following varieties will yield sufficient stability:
○4-or 6-hole mandible plate 2.0 with or without centerspace
○4-or 6-hole small profile locking plate 2.0
○4-or 6-hole medium profile locking plate 2.0
○4-or 6-hole large profile locking plate 2.0 (straight or curved)
5

Reduction
5
MMF
● Rigidfixationofamandibularfractureinthedentatepatientsbeginswithfixationoftheocclusion.Thesurgeon
hasthechoiceofusingarchbars,MMFscrews,orlocalwiringtechniques.
● ConsiderationsofwhichMMFtechniquetobeusedwilldependonfracturemorphology,associatedinjuries,
andpersonalpreference.
Manual Reduction
● Reductionofthefragmentsisdonemanuallyorwiththeuseofelevatorsorbonehooks.Agrossreduction
isdonepriortotheMMFapplication.FinetuningforpreciseanatomicalreductionisdonewithMMFin
place.
● Themaintenanceofthereductionwithaconventionalclampbecomesmoredifficultthefurtherposterior
thefractureislocated.Theclampscanbeappliedintotinypredrilledholesintheoutercortexnot
interferingwithlaterplateplacement.
Maintaining Reduction
● Inthemidbodyandposteriorbodythereductioncanalternativelybeheldbytheintermaxillaryligaturesor
manuallybytheassistantusinganinstrument,eg,periostealelevator.

Fixation Of Superior Border Plate
5Plate Contouring
● Thebonysurfaceofthealveolarprocessinthemajorportionofthemandibularbodyisalmostflat.Therefore,platecontouringisgenerallynecessaryonlyin
thetransitionzonestotheangleandanteriormandible.
Drill First Screw Hole
•Holdtheplatewithanappropriateinstrument
(eg,periostealelevatororforceps).
•Usea1.5mmdrillbitwith6mmstoptodrill
monocorticallythroughtheplateholenextto
thefracturelineintheanteriorfragment.
•Thesurgeonmustbeawarethatacortical
platemaybeverythininthisregionand
damagetothetoothrootsisstillpossible
usinga6mmdrillbitwithstop.
Insert Screw
Insert a 2.0 mm screw, 6 mm in length. Do not fully tighten
it until the final reduction and plate position are confirmed.
Insert Second Screw
Insertasecondscrewintheholenextto
thefracturelineintheposteriorfragment.
Theelevatorisusednowtokeepthefar
endoftheplateatthecorrectverticallevel.
Tightenbothscrews.
Theclampcanberemovedafterwards.
Additional Screw
Placement
Filltheremainingplate
holeswithscrewsinan
orderly fashion
continuingfromtheplate
holesnexttothefracture
totheouterplateholes.

Fixation of Lower Border Plate
5
Plate Contouring
● Accordingtotheprofileoftheselectedplate,thecontouringmaybemoreorlesstechnicallydemanding.
Usuallyastraightplatecanbeinsertedatthelowerborderofthemandibularbody.Adjustmentstothe
bonysurfacemustbemadebyout-of-planebending.
● Forlargerplateprofilestheuseofamalleabletemplateishelpful.Thisminimizestheriskofmentalnerve
injuryasrepeatedplateinsertionisavoided.
● Correctplatecontourandadaptationmustbecheckedeitherbydirectvisionorbyprobingwithablunt
instrument.
● Ensurethattheplateislocatedonboneoveritsfulllengthsothatallscrewswillengageinthebone.
Improvedvisioncanbeobtainedusingappropriateretractorswithfiberopticlighting.Alternatively,some
surgeonsadvocatetheuseofanendoscope.
Plate Insertion
● Anobstacletoplateplacementaretheexitingbranchesofthementalnerve.Thisarearepresentsa
dangerzonefornervedamage.Theboneregionbelowthebranchesmustbedissectedcarefully.The
plateispositionedintheareabelowthementalforamen.Thenervebranchesmustbemobilizedoutof
thefieldduringtheintroductionoftheplate.Duringscrewplacementinthementalnervearea,thenerve
branchesmustbeprotected.
● Transbuccalinstrumentationmaybeneededforproperposteriorscrewinsertion.
● Thefixationofthelowerborderplateisachievedusinga6-holeconventionalminiplatewithbicortical
screwfixation.

Fixation of Lower Border Plate
5
Drill First Screw Hole
● Holdtheplatewithanappropriateinstrument
(eg,periostealelevatororforceps)
● Usea1.5mmdrillbittodrillthroughtheplate
holenexttothefracturelineintheanterior
fragment.
Insert First Screw
● Priortoscrewinsertion,determinethe
appropriatescrewlengthusingadepthgauge.
● Inserta2.0mmscrewofappropriatelength.Do
notfullytightenituntilthefinalreductionand
platepositionareconfirmed.
Insert Second Screw
● Insertasecondscrewintheholenexttothe
fracturelineintheposteriorfragment.The
elevatorisusednowtokeepthefarendofthe
plateatthecorrectverticallevel.
● Tightenbothscrews.
● Theclampcanberemovedafterwards.
Additional screw placement
•Filltheremainingplateholeswith
screwsinanorderlyfashion
continuingfromtheplateholesnext
tothefracturetotheouterplateholes.
Final check
•ReleasetheMMFandcheckthe
occlusionforaccuracyandthebony
surfacesforpreciseanatomic
reduction.

ORIF: One Large Plate
Principles:
6
Main Indications
● Reducedbonebuttressingrequiringloadbearingfixation.
● Furtherindications
○ Delayedfracturetreatment
○ Infection
○ Pseudarthrosis
○ Nonunion
○ Ifmorestabilityisrequired.
Choice of Implant
● Thereareseveraladvantagestoalockingplate/screwsystem:
1. Conventionalplate/screwsystemsrequirepreciseadaptationoftheplatetothe
underlyingbone.Withoutthisintimatecontact,tighteningofthescrewswilldrawthebone
segmentstowardtheplate,resultinginalterationsinthepositionoftheosseoussegments
andtheocclusalrelationship.Lockingplate/screwsystemsoffercertainadvantagesover
otherplatesinthisregard;themostsignificantbeingthatitbecomesunnecessaryforthe
platetointimatelycontacttheunderlyingboneinallareas.Asthescrewsaretightened,
they"lock"totheplate,thusstabilizingthesegmentswithouttheneedtocompressthe
bonetotheplate.Thismakesitimpossibleforthescrewinsertiontoalterthereduction.
2. Anotherpotentialadvantageinlockingplate/screwsystemsisthattheydonotdisrupt
theunderlyingcorticalboneperfusionasmuchasconventionalplates,whichcompress
theundersurfaceoftheplatetothecorticalbone.
3. Athirdadvantagetotheuseoflockingplate/screwsystemsisthatthescrewsare
unlikelytoloosenfromtheplate.Thismeansthatevenifascrewisinsertedintoafracture
gap,looseningofthescrewwillnotoccur.Similarly,ifabonegraftisscrewedtotheplate,
alockingheadscrewwillnotloosenduringthephaseofgraftincorporationandhealing.
Thepossibleadvantagetothispropertyofalockingplate/screwsystemisadecreased
incidenceofinflammatorycomplicationsduetolooseningofthehardware.
4. Lockingplate/screwsystemshavebeenshowntoprovidemorestablefixationthan
conventionalnonlockingplate/screwsystems.
• Oneofthefollowingplatesshouldbechosenforfixationattheinferiorborder:
• 6-to8-holelargeprofilelockingplate2.0
• 6-to8-holeextra-largeprofilelockingplate2.0
• 6-to8-holelockingreconstructionplate2.4.
• Withtheuseofconventionalscrews,lockingplatescanbeconvertedintoconventional
nonlockingplatingsystemsusingfrictionbetweentheplateandthebonysurface.
• Screwapplicationisbicortical.

Reduction
6
MMF
Rigidfixationofamandibularfractureinthedentatepatientsbeginswithfixationofthe
occlusion.Thesurgeonhasthechoiceofusingarchbars,MMFscrews,orlocalwiring
techniques.
ConsiderationsofwhichMMFtechniquetobeusedwilldependonfracturemorphology,
associatedinjuries,andpersonalpreference
Anatomic Reduction
Usinganextraoralapproach,forcepscanbeusedtomanipulatethemandibularfragments
intoproperreduction.

Fixation
6
Plate Selection
Foratrueloadbearingfixation,a
reconstructionplate2.4shouldbe
used.Theplatemustbelong
enoughsothattherecanbea
minimumofthreescrewsoneach
sideofthefracture.Thescrews
adjacenttothefractureshouldbe
atleast7mmawayfromthe
fractureline.Mostcommonlythere
willbeoneortwoholeswithout
screwslocatedoverthefracture.
Thereareadvantagestousinga
lockingreconstructionplate
system.
Plate Adaptation
Theplatemustbecontouredtothelateral
surfaceofthemandible,flushwiththe
inferiorbordertoavoidinjuringtheinferior
alveolarnerve.Intheanteriorbodyregion
thebranchesofthementalnervemustbe
sparedduringplateintroductionand
adaption.
Securing The Plate To The Bone With Bone Clamps
Inserttheproperlycontouredplateontothelateral
surfaceofthemandibleandholditthereusingball
pointedreductionforceps.Ideally,onesetofforceps
isappliedanteriorandonesetposteriortothe
fracture.
Inserting Screws
Thesequenceofscrewinsertionisnotimportantifthe
plateissecurelyclampedtothebone.Drillguides
shouldalwaysbeusedtocenterthescrewwithinthe
platehole.

Complex Mandibular
Body Fracture
Management

CLOSED Treatment
Main Indications
○In rare cases, in compliant patients with good dentition and non-or minimally displaced fractures.
Further Indications
○ Premorbid or unstable medical condition preventing general anesthetic
○ Conditions making open reduction and internal fixation difficult
○ Patient refusal of operative treatment
○ Unavailability of plates and screws
Special Consideration
○MMF may be contraindicated in patients with psychiatric disorders, seizure disorders, and alcoholics.
1

Treatment
● Apply arch bars in the mandible and maxilla.
● Reduce the bony deformity as far as possible in a closed manner prior to putting the patient
into occlusion. Apply intermaxillary ligatures to maintain the occlusal position.
● The patient has to be maintained in MMF for at least 6-8 weeks.
1
● Pearl: individual laboratory designed arch bars
● After taking impressions individual arch bars can be fabricated on plaster of pariscasts. Prior
to the arch bar fabrication these casts are sawed and the fracture is reduced (see blue zone
on the cast).
●Closed treatment of complex fractures of the body
•Thus, the arch bar helps in the reduction. Furthermore, individual arch bars prevent damage of the
periodontal soft tissues and are less invasive.

ORIF: Two Plates (Basal Triangle)
Biomechanics
• All biomechanical models developed to date have shown that two points of fixation (ie, two plates) provide much more stability
than a single one.
• The basal triangle decreases the bone buttressing and interfragmentary support. This condition demands a degree of stability
beyond pure load sharing.
• Therefore when more stability is deemed necessary, the addition of a second plate provides more rigidity.
Sequence of plate insertion
● The superior plate is inserted first in order to achieve preliminary fixation. This will prevent inadvertent displacement of the
fragments during subsequent contouring and the insertion of the inferior border plate.
Main Indications
○Basal triangle fracture..
SURGICAL APPROACH
Accessibilitytotheinferiorborderofthemandibleviaanintraoralapproachdecreasesfromtheanteriortotheposteriorbodyregion.
Underfavorablecircumstancesthebasaltriangularfracturesintheanteriorbodyregioncanbetreatedtransorally.Inthemidbodyor
posteriorbodyregionthereductionofthetrianglemaybesodifficulttoachievetransorallythatatransbuccalinstrumentationmaynot
behelpful.Anexternalsubmandibularapproach(occasionallysupplementedwithasubmentalappraoch)isoftennecessaryforan
accuratereductionandfixation.Existinglacerationsmayalsobeused.
2
PRINCIPLES

Superior border plate
The superior border is treated with a tension band plate with monocorticalscrew fixation. The
profile of this plate can be minimal.
The plate selection can be as follows:
○ 4-or 6-hole mandible plate 2.0 with or without centerspace
○ 4-or 6-hole small profile locking plate 2.0 with or without centerspace
Inferior border plate
Only large profile plates meet the biomechanical requirements of basal triangular fractures.
One of the following plates should be considered for fixation at the inferior border. The chosen
plate should allow for a fixation of the triangle to the plate. This precludes the use of plates with
a centerspace.
○ 6-to 8-hole large profile locking plates 2.0
○ 6-to 8-hole extra large profile locking plates 2.0
○ Screw application is commonly bicortical.
2
Choice of Implant

Reduction2
MMF
Rigidfixationofamandibularfractureindentatepatientsbeginswithfixationoftheocclusion.The
surgeonhasthechoiceofusingarchbars,MMFscrews,orlocalwiringtechniques.
Inthemandiblebodyfractureswithbasaltriangularfragments,anarchbarispreferablyappliedfor
MMF.Thisequatestoanotherlineofresistanceinparticularwiththebitingloadanteriortothe
fractureline.Thearchbarshouldincludeatleastallteethintheaffectedquadrantofthejaw.Itis
notnecessarytoencompassthewholedentalarch.Theapplicationofthearchbarisunproblematic
becauseonlyonefracturelinerunsthroughthealveolarprocessandisnotaffectedbythetriangular
fragmentation.MMFbonescrewsonlyprovidetemporaryfixationduringsurgeryanddonot
contributepostoperativelytostabilization.
Reduction of the main fragments
Reductionofthefragmentsisdonemanuallywiththeuseofelevators,bonehooks,orbonescrews
insertedashandles.GrossreductionisdonepriortotheMMFapplication.Finetuningforprecise
anatomicalreductionisbestdonewithMMFinplace.Themaintenanceofthereductionofthe
alveolarportionofthefracturewithaconventionalclampbecomesmoredifficultthefurther
posteriorthefractureislocated.Ifpossible,aclampisappliedintotinypredrilledholesintheouter
cortexinanareathatwillnotinterferewithlaterplateplacement.Themainfragmentsarereduced
asafirststep.Ensurethatthebasaltriangleislooseenoughtobereducedsecondarilyintothe
remainingbonegap.
Fromevaluatingthepreoperativeconventionalx-raysitisassumedthatthebasaltriangleisa
singleandsolidbonytriangle.ItbecomesapparentfromCTscanningthatbasaltrianglesareoften
dividedintoanouterandinnertablefragmentwhichmakesreductionmoredifficult.Theinner
fragmentwillnotusuallybeaccessibleusinganintraoralapproachonlyexposingthelateralsurface
ofthemandible.

Fixation of Superior Border Plate
2
Plate Contouring
Thebonysurfaceofthealveolarprocessinthemajorportionofthemandibularbodyisalmostflat.Therefore,platecontouringisgenerallynecessaryonly
inthetransitionzonestotheangleandanteriormandible.
Drill First Screw Hole
Holdtheplatewithanappropriateinstrument
(eg,periostealelevatororforceps).
Usea1.5mmdrillbitwith6mmstoptodrill
monocorticallythroughtheplateholenexttothe
fracturelineintheanteriorfragment.
Thesurgeonmustbeawarethatacorticalplate
maybeverythininthisregionanddamageto
thetoothrootsisstillpossibleusinga6mmdrill
bitwithstop.
Insert screw
Inserta2.0mmscrew,6mminlength.Donotfully
tightenituntilthefinalreductionandplateposition
areconfirmed.Twoplatefixationofbasaltriangle
bodyfractures
Insert second screw
Insertasecondscrewintheholenexttothefracture
lineintheposteriorfragment.Theperiostealelevator
isusednowtokeepthefarendoftheplateatthe
correctverticallevel.Tightenbothscrews.Theclamp
canberemovedafterwards
Additional screw placement
Fill the remaining plate holes with screws in
an orderly fashion continuing from the plate
holes next to the fracture to the outer plate
holes.

Reduction of The Basal Triangle
2
Thebasaltriangleitselfmustberepositionedbypushinganddraggingwithan
appropriateinstrument.Usingatransoralapproach,thelingualcortexofthemandible
canonlybeaccessedwiththeadditionofapercutaneoushook.Ifaseparationofthe
basaltriangleintoaninnerorouterpiecehasbeenassessedradiographicallythe
reductionshouldbeperformedviaasubmandibularapproach.
Tokeepthebasaltriangleinplaceitcanbecompressedbetweenthegreater
fragments.Onealternativeisatemporaryfixationusingaminiplate(asillustrated)that
willnotinterferewiththeplannedpositionoftheinferiorborderplate.
Inatransoralapproach,temporaryplatefixationistobelocatedintheupperangleof
thetriangleallowingittobepulledupwardsintothegapbetweenthelargefragments.
Inasubmandibularapproachthetemporaryfixationcanbeachievedwitha
horizontallyorientedplatealongthebasalaspectofthemandibularborder.Viaa
submandibularapproach,thepositionofthebasaltriangleandtheadjacentmajor
fragmentcanbecontrolledthreedimensionally.Nonetheless,separatefragmentsof
theinnercortexwillnotbeamenabletosubsequentfixation.

Fixation of Lower Border Plate
2
PlateContouring
Contouringoflargeprofileplatesisdemanding.Usuallyastraightplatecanbeinsertedatthelowerborderofthemandibularbodyoverlyingthe
reducedbasaltriangle.Adjustmentstothebonysurfacemustbemadebyout-of-planebending.Ifscrewplacementintothebasaltriangleis
intended,theplateispositionedwithatleastoneholeoftheplateoverlyingthetriangle.Theuseofamalleabletemplatemaybehelpful.This
minimizestheriskofmentalnerveinjuryasrepeatedplateinsertionisavoided.Correctplatepositionandadaptationmustbecheckedeitherby
directvisionorbyprobingwithabluntinstrument.Ensurethattheplateislocatedonboneoveritsfulllengthsothatallscrewsengagethebone.
Improvedvisioncanbeachievedbyusingappropriateretractorswithfiberopticlighting.Alternatively,somesurgeonsadvocatetheuseofan
endoscope.
PlateInsertion
Anobstacletoplateplacementaretheexitingbranchesofthementalnerve.This
arearepresentsadangerzonefornervedamage.Theboneregionbelowthe
branchesmustbedissectedcarefully.Theplateispositionedinthespacebelow
thementalforamen,ifnecessary.Thenervebranchesmustbemobilizedoutof
thefieldduringtheintroductionoftheplate.Duringscrewplacementinthe
mentalnervearea,thenervebranchesmustbeprotected.
Notethatthescrewfixingthebasalsegmentislockedtotheplate.
Thefixationofthelowerborderisachievedusinga7-holelargeprofilelocking
platewithbicorticalscrewfixation.Thebasaltriangleisprefixedwithaminiplate
attheapex.

2
DrillFirstScrewHole
Holdtheplatewithan
appropriateinstrument
(eg,periostealelevatoror
forceps).Usea1.5mm
drillbittodrillbicortically
throughtheplatehole
nexttothefracturelinein
theanteriorfragment.
Insert First Screw
Priortoscrewinsertion,determine
theappropriatescrewlengthusing
adepthgauge.Inserta2.0mm
screwofappropriatelength.Do
notfullytightenituntilthefinal
reductionandplatepositionare
confirmed
Insert Second Screw
Insertasecondscrewinthehole
nexttothefracturelineinthe
posteriorfragment.Theelevatoris
usednowtokeepthefarendof
theplateatthecorrectvertical
level.Tightenbothscrews.
Additional screw placement
Filltheremainingplateholeswithscrewsinan
orderlyfashioncontinuingfromtheplateholes
nexttothefracturetotheouterplateholes.
Finallythebasaltriangleissecuredwithan
additionalscrew.Alockingheadscrewis
preferredoveraconventionalscrewtoavoid
secondarydisplacementofthebasaltriangle.
Thescrewcanbeinsertedeither
monocorticallyorbicorticallydependingon
whetherthetriangleisseparated.
Removal of Miniplate
Ifthebasaltriangleisfixedtothelarge
plateatthelowerborderofthemandible,
theminiplateusedforitstemporary
fixationcanberemoved.ReleasetheMMF
andchecktheocclusionforaccuracyand
thebonysurfacesforpreciseanatomic
reduction.

ORIF: Reconstruction Plate
Main Indications
○Standard method of treatment of a comminuted fracture.
GeneralConsiderations
Aload-bearingfixationisindicatedfortheopensurgicaltreatmentinalltypesofcomminutedfracturesinthemandibularbody.Historically,
manysurgeonshavebeenreluctanttoopencomminutedfractures,fearingthatthesmallbonyfragmentswillbecomedevascularizedand
resultinsubsequentinfectionandsequestration.Althoughthiscomplicationisstillapossibility,surgeonshavedemonstratedadistinct
advantageinORIFofcomminutedfractures.Theload-bearingfixationbridgestheareaofcomminution.Thebonefragmentswithinthearea
ofcomminutiondonotprovidebuttressingforloadtransmissionbetweentheadjacentintactportionsofthemandible.Thereconstruction
plateisfixedwithatleastthreeandpreferablyfourscrewsoneachsideofthecomminutedarea.
3
PRINCIPLES
Stepwiserepair:simplificationpriortoload-bearingreconstruction:
Whentreatingcomminutedmandibularbodyfractures,thesurgeonshouldproceedina
stepwisefashion.AfterplacingthepatientinocclusionandsecuringMMF,the
comminutedfracturesaresimplifiedusingminiplates.Theload-bearingfixationis
performedasasecondstep.Tosimplifythefracturepatternwithinacomminutedarea
thesmallfragmentsarereducedandfixedtoeachother,inordertobuilduplargerbone
compoundsthatwillfitintothegap.Thesebonecomponentsareusedforrealignmentof
theoverallboneshapeandwillhelpthecontouringofthereconstructionplatealongthe
realignedlowermandibularborder.

ORIF: Reconstruction Plate3
PRINCIPLES
ChoiceofImplant
Thereareseveraladvantagestoalockingplate/screwsystem:
1.Conventionalplate/screwsystemsrequirepreciseadaptationoftheplatetotheunderlyingbone.Withoutthisintimatecontact,tighteningofthe
screwswilldrawthebonesegmentstowardtheplate,resultinginalterationsinthepositionoftheosseoussegmentsandtheocclusalrelationship.
Lockingplate/screwsystemsoffercertainadvantagesoverotherplatesinthisregard;themostsignificantbeingthatitbecomesunnecessaryfor
theplatetointimatelycontacttheunderlyingboneinallareas.Asthescrewsaretightened,they"lock"totheplate,thusstabilizingthesegments
withouttheneedtocompressthebonetotheplate.Thismakesitimpossibleforthescrewinsertiontoalterthereduction.
2.Anotherpotentialadvantageinlockingplate/screwsystemsisthattheydonotdisrupttheunderlyingcorticalboneperfusionasmuchas
conventionalplates,whichcompresstheundersurfaceoftheplatetothecorticalbone.
3.Athirdadvantagetotheuseoflockingplate/screwsystemsisthatthescrewsareunlikelytoloosenfromtheplate.Thismeansthatevenifa
screwisinsertedintoafracturegap,looseningofthescrewwillnotoccur.Similarly,ifabonegraftisscrewedtotheplate,alockingheadscrewwill
notloosenduringthephaseofgraftincorporationandhealing.Thepossibleadvantagetothispropertyofalockingplate/screwsystemisa
decreasedincidenceofinflammatorycomplicationsduetolooseningofthehardware.
4.Lockingplate/screwsystemshavebeenshowntoprovidemorestablefixationthanconventionalnonlockingplate/screwsystems.
Reduction/fixation-generalconsiderations
1.ReducethemainfragmentsadjacenttothecomminutedareaandfixthemusingocclusionandMMF.Now,thesizeanddimensionofthe
comminutedareaaredefined.Startwithrealignmentofthecomminutedfragments.Itisconvenienttoregroupthelargerfragmentsintosubunits.
Thesesubunitsareconnectedwithmonocorticalminiplatefixationandusedasbuildingblocksforsimplificationandreestablishingthebony
continuityacrossthecomminutiongap.Shatteredbonepiecesareeitherreducedandleftloose,orcanbefixedusingminiplates.
2.Iftinypieceshavelosttheirmucosalattachmentsandaredevascularized,itissometimesadvisabletoremovethem.
3.Note:Forthesimplificationofthefragmentsinsidethecomminutedzone,reductionandfixationcanalternatetoachievebonecontinuityina
stepwisefashion.

ORIF: Reconstruction Plate3
MMF
•Intheisolatedmandiblebodyfracture,anarchbarispreferredforMMF.Thisequatestoa
secondlineofresistanceinparticularwithbitingloadanteriortothefractureline.
•MMFbonescrewsprovidetemporaryfixationonlyduringsurgeryanddonotcontributeto
stabilizationpostoperatively.
Realignmentandfixationoffragmentsatthesuperiorborder
•Theintactportionsadjacenttothecomminutedareaarereducedasafirststep.
•Thecomminutedzonecanthenbesimplifiedtoreducethesmallerfragmentsintoonelargefragmentby
usingminiplates.
•Thisisbestdonebystartingatthesuperiorborder(alveolarprocess).
•Reductionofthefragmentsisdonemanuallyorwiththeuseofelevatorsorbonehooks.
•Onelongplatecanbeselectedtospanandadaptallalveolarprocessfragmentsatonce.Thiscanbemore
difficultthanusingseveralshortplatessincetheseallowforfinetuningthereductionofeachindividual
fragmentbeforeinsertingtheload-bearing(basal)plate.Miniplatesarecutandcontouredandfixed
monocortically.Sometimeslagscrewscanalsobeuseful.
SIMPLIFICATION

ORIF: Reconstruction Plate3
Realignmentandfixationoffragmentsattheinferiorborder
Afteraframeworkhasbeencreatedatthesuperiorborder,thesimplificationprocessiscontinuedatthe
inferiorborder.Reductionofthefragmentsisdonemanuallyorwiththeuseofelevators,boneclamps,or
bonehooks.
SIMPLIFICATION
The fragments are reduced and fixed either one
by one or fixed all simultaneously.
Pearl: manipulating fragments
Insert a monocorticalscrew into the centerof
larger bone pieces. The fragment can then be
moved (dragged) with the help of a ligature forceps
attached to the screw head.

3
Choiceofimplant
Alockingreconstructionplate2.4istheimplantofchoicewithanadequatelength(atleastthreeholeson
eithersideofthefracturezonearerequired)straightorprebentforuseintheangle..
Fixation of lower border reconstruction plate
Plate Contouring
Contouringofreconstructionplatesisdemanding.Astraightplatecanbe
insertedatthelowerborderofthemandibularbodybridgingthecomminution
zoneifthisisconfinedtotheanteriorandmidbodyregion.Ifthecomminution
zoneextendstowardstheangleaprebentplateisadvantageous.
Theuseofamalleabletemplateisstronglyadvocatedforaccurateplate
contouring.Theriskofmentalnerveinjuryislowsincethenerveisreflected
outofthefieldduetotheupwardsoft-tissueretraction(submandibular
approach).
Thecorrectplatecontourandadaptationischeckedvisually.Ensurethatthe
plateislocatedonboneoveritsfulllengthsothatallscrewswillengagein
thebone.Ascrewfixationoftherealignedfragmentsalongtheinferior
mandibularbordershouldbepossiblewithease.Therefore,theplatemustbe
contouredaccordingly.

3
Fixation of lower border reconstruction plate
Temporary fixation of the reconstruction
plate by holding forceps
Fix the plate to the intact bone portions using the
holding forceps.
Drill first screw hole
Use a 1.8 mm drill bit to drill bicorticallythrough
the plate hole. The first screw can be placed in
any plate hole over either the anterior or posterior
bone portion.
Insert first screw
Prior to screw insertion determine the appropriate screw
length using a depth gauge. Insert a 2.4 mm locking head
screw of appropriate length.
1 2
3
4
Insert second
screw
The second 2.4
locking head screw
is inserted into a
plate hole over the
opposite intact bone
portion.
Additional screw placement
Fill the remaining plate holes over the intact bone portions
with 2.4 mm locking head screws.
Finally the basal fragments are secured centrally with
additional 2.4 mm locking head screws. A locking head screw
is preferred over a conventional screw to avoid secondary
displacement. The screws can be inserted either mono-or
bicorticallydepending if the fragments are split sagittallyor
not.
Conventional screws placed at an angle can be used to
stabilize large fragments.
5

3
Fixation of lower border reconstruction plate
Removal of basal adaptation plate
The surgeon has the option of removing the basal adaptation plate according
to personal preference.
Final check
Release the MMF and check the occlusion for accuracy and the bony surfaces for precise
anatomic reduction.
WOUND CLOSURE
Intraoral wound closure
The intraoral wound closure has to take into account mucosal lacerations and tooth and bone loss. Appropriate flaps and mucoperiosteal
undermining have to be chosen to achieve a water-tight wound closure.
Extraoral wound closure
Extraoral wound closure is done in a standard manner. The use of a suction drain may be considered

External Fixator4
PRINCIPLES
Temporaryversusdefinitivetreatment
Theoretically,themandibularexternalfixatorcouldbeusedtoachievedefinitive
bonehealing.Nevertheless,theexternalfixatordoesnotofferthesamedegreeof
stabilitycomparedtointernaldevices(reconstructionplates).
Mostoften,theapplicationoftheexternalfixatordevicewillbeonatemporary
basisonly,withsubsequentreplacementbyaninternalfixationsystem.
Framedesign
Theexternalpinfixationdevicegivesahighdegreeoffreedomfortheframe
assemblyasthepinscanbeplacedselectivelyintoeachsegmentandconnected
withshortbarstoconstituteasubunit.Subsequently,thesubunitsarejoinedwith
furtherconnectingelementstomakeupthecompleteframework.Inthisprocess
eachsubunitcanbemanipulatedintoareducedpositionuntilfinaltighteningof
thewholeconstruct.
Otherlimitationsofexternalfixators
Somedisadvantagesofanexternalfixatorare:
•Theextensiveamountofhardwarenecessarytothecomplexconstruction
•Thequalityofthebonyreductionisnotguaranteedasthefragmentends
arenotoftensurgicallyexposed
GeneralConsiderations

Main Indications
○ Temporary stabilization of complex fractures
simultaneously affecting several anatomic
mandibular subunits.
Advantages
○ Maintain fragment position without disrupting
the blood supply
○ Rapid application
4
Alternative:biphasicpinfixation
Analternativetothemodulartechniqueisthebiphasicpinfixation(alsoknownasJoe
HallMorrisfixation).
Subsequenttothefirstphasewherefracturealignmentisachievedwithadjustable
connectingrodsbetweenthepinpairs(notshownintheillustration),isthesecond
phasewhenthealignedpinsarecoveredwithasilicontube,eg,endotrachealtube,
injectedwithmethylmethacrylateresin.Alternativelythepinscanbeconnectedwitha
moldableplasticshieldthathardensafterapplication.
Finallytheadjustablerodsareremoved.Thisprocedureishighlyflexibleandresultsina
leanconstruct.
GeneralConsiderations
BiomechanicalConsiderations
To optimize the framework stability it is recommended to:
• Choose large pin diameters
• Use at least two pins in each fragment
• Keep a large distance between the pin pairs
• Place pins next to fracture line as close as possible to the fracture line but
not less than 1 cm
• Place the connecting rods or plastic bar close to the skin surface in order
to keep the lever arms short.

4
MMF
Ifthemajorfragmentsareabletobe
alignedusinganyofthecurrentMMF
techniques,theseareusedfor
simplificationoftheoverallassembly
process.
General consideration for
pin insertion
Thepininsertionisdone
throughthesoft-tissue
envelopeoverlayingthesafe
zones.Apairoftwopins,if
possible,isinsertedinto
eachmajorfragmentat
appropriatedistancetoeach
otherandtheadjacent
fracturelines.Thelengthof
thethreadedportionofthe
pinsischosentoattain
bicorticalengagement.
1
2
Stab incision
Makeasmallstabincisiontoprepareforpin
insertionatthepredeterminedscrewlocationsin
theposteriormandible.Thestabincisionisdone
withthebladeparalleltotheRSTL(relaxedskin
tensionlines).
3
4
Soft-tissue dissection
and protection
Bluntlydissectasoft-tissue
canalontotheboneandpass
atrocarforsoft-tissue
protectionthroughthecanal
untilitcontactsthebone.
Aself-drillingpinisloadedintoahandle.Usingthetrocarasa
guide,thepinisdrivenintothebonedowntoitsstoppingbevel.
Thenthehandleisdisengagedfromthepinandthetrocaris
removed.
Ifaself-drillingpinisnotavailableornotadvisabledueto
fragmentinstability,makesuretopredrillpriortopininsertion.
5

4
Creation of subunits
Thetwopinsineachfragmentare
connectedwitharodandtwoclamps
(asillustrated).Theexamplehereshows
foursubunits
6
Linking the two posterior subunits
1.)Applyaconnectingrodlooselybetween
twosubunitsusingrod-to-rodclamps.
2.)Onefractureismanuallyreducedby
manipulatingtwosubunits.
7
Linking the anterior subunits & Tighten
the rod-to-rod clamps
8
Final frame assembly
Nowonlyonefracturegapisleftbetweentwolarge
assembledmandibularportionsasaresultof
connectingtheanteriorandposteriorsubunits.This
gapisreducedandfixedthroughaconnectingrod.
9
10
MMF is removed after the final external
fixator assembly to allow for mandibular
function.
Alternative: using a bow
Whenalargecircumferenceofthemandible
requiresexternalfixation,abow-shapedrodcan
bedirectlyattachedtothepins.
11

COMPLICATIONS
07

Immediate complication
1.Airways obstruction
2.Nasal hemorrhage
3.Cerebral complication
4.Insecure fixation
5.Ophthalmic complications
6.Inaccurate fixation
During Primary Treatment
1.Infection: Seen more in diabetic patients or
patients with reduced immunity, steroid
therapy.
2.Nerve injury: Damage to inferior alveolar
nerve or facial nerve leading to anesthesia
of lower lip, face etc.
3.Displaced teeth and foreign body being
aspirated.
4.Pulpitis, gingival and periodontal
complications.
5.Misapplied fixation
6.Drug reactions
Late Complications
1. Malunion:
a. Dysarthrosis-Morphological changes in unreduced dislocated fragments leading to
limited movement and pain.
b. Metaarthrosis-Anatomically altered but functionally accepted union leading to
noseveresymptoms.
c.Pseudoarthrosis-Falsejointleadingtoseverepainduringmovement.Thisiscaused
duetoformationofcartilaginoustissuesoverfracturedboneandwithacavityin
between,containingclearfluid.Thisisnotablyseeninoldfractures.
Causes of malunion:
–Improper fixation
–Early mobilization
–Tissue entrapment
2.Delayed union
Causes of delayed union:
–Infection
–Old age
–Nutritional deficiency
3.Nonunion(eburnation)
Caused of nonunion:
–Infections
–Improper immobilization
–Inadequate approximation
–Ultra thin, edentulous mandible
–Excess loss of bone and soft tissue
–Inadequate blood supply
–Bony pathology like tumor
–General systemic diseases
–Sequestration of bone
–Scar formation in the region
4.Bony deformity and facial skeleton Flattening
5. Diplopia and Visual disturbance/ OthlmaicComplications
6. Malocclusion

Post-Operative Care
08

Immediate post-operative Care
●Patient must be observed under skilled nurse until, complete recover.
●IMF has been carried:
○Wire cutter near the bed
○nasopharyngeal tube until complete recovery.
○suction tip for secretion
○Patient lying 45degree
○reduce post operative vomiting through skilled anaesthetist.

Intermediate Post-Operative Care
●Painless reduction immobilized over the fractured site and edema subsided pain, tenderness palpation with
increase body temperature indicates infection.
●Alert patient posture is upright, while Comatose patient is lying on his side so that saliva, blood dribble out the
mouth.
●Efficient reduction, immobilization does not need analgesic
●Powerful analgesic as Morphine will hide important physical sign as pupil dilatation, cerebral hemorrhage, depress
respiratory center.
●Infection prevention is through penicillin 9 mega unit.
●Oral hygiene
●Petroleum jelly to lip to prevent dryness
●Feeding is according to conscious level of the patient:
○Conscious patient need !&AA calorie per day in form of semifluid or fluid nutrition food as Complanas high
protein and minerals. Transnasalgastric tube is also used. Small cup with suction tube.
○Unconscious patient need 2AAAml/day. Urine output is about 9&AA ml./ potassium, sodium are analyzed.
Increase nitrogen is due tissue breakdown.IV. dextrose, saline and glucose./Enteral Fluid Therapy(Ryle’s tube)

Late Post-Operative Care
●Normal healing of both mandible and maxilla in adult patient is about 7
weeks.
●While fracture Children need 3-4 weeks.
●Elderly patient need 6-8 weeks or with infected fracture
●Mobilization of TMJ to prevent ankylosis, as early.
●Parasthesiaor anesthesia due to neurotmesis, neuropyraxiais about 6
months till I ½ year or may permanent loss sensation of lip, anterior 1/3 of
the tongue, infraorbital area.
●Gingivitis gum growth over the wire.

Aftercare Following Closed Treatment of Mandibular Body Fractures
●ThepatientshouldbeinstructedhowtoreleasetheMMFincaseofemergency.Somesurgeonsprefertoprovidewirecutterstothepatientfor
theperiodofMMF.Duringthisperiod,wirefatigueandlooseningcanoccur.ThepatientshouldreportanylooseningoftheMMFtothe
surgeonimmediately.
●Asanalternative,theMMFmaybeachievedbyusingelasticsinsteadofwires.Withanadequatenumberofelastics,thesamelevelof
reliabilitycanbereachedminimizingtheriskofaccidentsduringanemergencysituation.
●Postoperativex-raysaretakenwithinthefirstdaysaftersurgery.Inanuneventfulcourse,follow-upx-raysaretakenpriortoreleasingtheMMF.
●Itwillbenecessarytoseethepatientapproximately1weekpostoperativelytoassessthestabilityoftheocclusionandtocheckforinfectionof
thesurgicalwound.Theintermaxillaryfixationwiresorelasticsmustbeassessedandproventoholdthepatienttightlyinocclusion.Patients
alsohavetobeperiodicallyre-examinedtoruleoutsignsofinfection.Ateachvisit,thesurgeonmustevaluatepatientabilitytoperform
adequateoralcleaning.Itmaybenecessarytoprovideadditionalinstructiontoassureappropriatehygieneandwoundcare.
●Adequatedentalcareisrequiredinmostpatientshavingsufferedamandibularfracture.
●Thereshouldbenomalocclusiondetectedasocclusionisdeterminedandsecuredintheoperatingroom.
●OnreleasingtheMMF,physiotherapycanbeprescribed.ThemandiblewillbehypomobileaftertheperiodofMMF,andthemuscleswillbe
atrophicand“tight.”Openingandexcursiveexercisesshouldbedemonstratedandimplemented.Goalsshouldbeset,andtypically,40mmof
maximuminterincisalmouthopeningshouldbeattainedby4weekspostoperatively.Ifthepatientcannotfullyopenhismouth,additional
passivephysicaltherapymayberequiredsuchasTherabiteortongue-bladetraining.

Aftercare Following Closed Treatment of Mandibular Body
Fractures
● Diet
The diet has to be in a liquid or semi-liquid form. For patients with a full complement of teeth, the diet must be more liquefied than when
there are gaps with teeth missing. Because the diet will be no-chew, more fluids are required to assist in swallowing the food. A blender,
or preferably, a juicer is useful. Anything can be made into a liquid or semi-liquid form with these tools. Liquid dietary supplements from
the grocery store help maintain caloric intake. The patient should monitor their body weight on a weekly basis during the periodof MMF
to evaluate any dramatic changes.
● Oral hygiene
Patients must be instructed in oral hygiene procedures. The presence of the arch-bars and MMF wires makes this a much more difficult
procedure, and the inside of the teeth cannot be reached with a toothbrush. A soft toothbrush (dipping in warm water makes softer)
should be used to clean the buccal/labial surfaces of the teeth, arch-bars and wires. Chlorhexidine oral rinses should be prescribed and
used at least 3 times each day to help sanitize the mouth. The tongue can be used to swipe the lingual surfaces of the teeth. With larger
debris, a 1:1 mixture of hydrogen peroxide/chlorhexidine can be used. The bubbling action of the hydrogen peroxide helps remove
debris. A Waterpik® is a very useful tool to help remove debris from the wires.
● Speech
Patients are told to speak as freely as possible. Over the course of 1–2 weeks, patients can usually speak quite intelligibly, although
voice projection remains difficult during the period of MMF
MMFrenderseating,speakingandoralhygienemoredifficult.Patientswillthereforehavetofollowthreebasicinstructions:

Aftercare following ORIF of Mandibular Body Fracture
Confirmation of Reduction
● IfarchbarsorMMFscrewsareusedintraoperatively,theyareusuallyremovedattheconclusionofsurgeryifproper
fracturereductionandfixationhavebeenachieved.Archbarsmaybemaintainedpostoperativelyiffunctionaltherapyis
requiredorifrequiredaspartofthefixation.
● Postoperativex-raysaretakenwithinthefirstdaysaftersurgery.Inanuneventfulcourse,follow-upx-raysaretakenafter4–
6weeks.
●Thepatientisexaminedapproximately1weekpostoperativelyandperiodicallythereaftertoassessthestabilityofthe
occlusionandtocheckforinfectionofthesurgicalwound.Duringeachvisit,thesurgeonmustevaluatethepatientsability
toperformadequateoralhygieneandwoundcare,andprovideadditionalinstructionsifnecessary.
●Adequatedentalcareisrequiredinmostpatientshavingsufferedamandibularfracture.
● Ifamalocclusionisdetected,thesurgeonmustascertainitsetiology(withappropriateimagingtechnique).Ifthe
malocclusionissecondarytosurgicaledemaormusclesplinting,trainingelasticsmaybebeneficial.Thelightestelastics
aspossibleareusedforguidance,becauseactivemotionofthemandibleisdesirable.Patientsshouldbeshownhowto
placeandremovetheelasticsusingahandmirror.
● Ifthemalocclusionissecondarytoabonyproblemduetoinadequatereductionorhardwarefailureordisplacement,elastic
trainingwillbeofnobenefit.Thepatientmustreturntotheoperatingroomforrevisionsurgery.
●Follow-up appointments are at the discretion of the surgeon, and depend on the stability of the occlusion on the first visit. If
a malocclusion is noted and treatable with training elastics, weekly appointments are recommended.

Aftercare following ORIF of Mandibular Body
●Diet
Depending upon the stability of the internal fixation, the diet can vary between liquid and semi-liquid to “as tolerated”, at the
discretion of the surgeon. Any elastics are removed during eating.
●Oral hygiene
Patients having only extraoral approaches are not compromised in their routine oral hygiene measures and should continue
with their daily schedule.
Patients with intraoral wounds must be instructed in appropriate oral hygiene procedures. The presence of the arch-bars
and any elastics makes this a more difficult procedure than normal. A soft toothbrush (dipping in warm water makes it
softer) should be used to clean the surfaces of the teeth and arch-bars. Any elastics are removed for oral hygiene
procedures. Chlorhexidine oral rinses should be prescribed and used at least three times each day to help sanitize the
mouth. For larger debris, a 1:1 mixture of hydrogen peroxide/chlorhexidine can be used. The bubbling action of the
hydrogen peroxide helps remove debris. A Waterpik® is a very useful tool to help remove debris from the wires. If a
Waterpikis used, care should be taken not to direct the jet stream directly over intraoral incisions as this may lead to wound
dehiscence.
●Physiotherapy
Physiotherapycan be prescribed at the first visit and opening and excursive exercises begun as soon as possible. Goals
should be set, and, typically, 40 mm of maximum interincisal jaw opening should be attained by 4 weeks postoperatively. If
the patient cannot fully open his mouth, additional passive physical therapy may be required such as Therabiteor tongue-
blade training
Postoperatively, patients will have to follow three basic instructions:

Aftertreatment Following Temporary External Fixation
●External fixation of the mandible is usually temporary. Conversion to, and the timing of conversion to internal plate
fixation is at the discretion of the surgeon. The general patient condition and local soft tissues must have become
suitable to allow this conversion.
●Meticulous daily pin care is necessary to avoid infections at the pin site and loosening of the hardware.
●The patient should be taught appropriate pin-track care. Soft tissues around external fixation pins are treated with pin-
site cleansing, antibacterial ointments and dressings.
Treatment of intraoral wounds
●In the presence of intraoral wounds, the appropriate guidelines for mouth rinses and diet have to be followed. Regular
appointments at short intervals are mandatory.

THANK
YOU
•Done By:
Shahd Hassan Elsayed Ragab Ibrahim
•PC ID: 201500822
•RegularID:5215146
•GP 13/14
•Mail: [email protected]

●Guidelines to Oral & Maxillofacial Surgery & Anesthesia; Fourth Edition, Faculty of Dentistry, University of Alexandria.
●Raymond Fonseca, H. Dexter Barber, Michael Powers, David E. Frost -Oral and Maxillofacial Trauma (2013, Saunders)
●AO Foundation (Davos, Switzerland)Mandible Fractures Pickrellet al. Seminars in Plastic Surgery Vol. 31 No. 2/2017
●James Hupp, Myron Tucker, Edward Ellis -Contemporary Oral and Maxillofacial Surgery (2018, Mosby _ Elsevier)
●FragiskosD. Fragiskos(Ed.) Oral Surgery The Journal of Craniofacial Surgery Volume 27, Number 6, September 2016
●Resident Manual of Trauma to the Face, Head, and Neck First Edition Textbook of Head and Neck Anatomy Fourth
Edition
●Management of Complications in Oral and Maxillofacial Surgery, First Edition. Edited by Michael Miloro, Antonia
Kolokythas. ©️2012 John Wiley & Sons, Inc. Published 2012 by John Wiley & Sons, Inc.
●Textbook of Oral and Maxillofacial Surgery; Jaypee Brothers; 3rd edition; 2012.
●Textbook of Oral & Maxillofacial Surgery; Elsevier India Pvt Ltd; 3rd edition; 2018.
●Illustrated Manual of Oral and Maxillofacial Surgery; Jaypee Brothers Medical Pub; 1st edition; 2009.
References

Fractures of The Body of The Mandible In Maxillofacial Surgery

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Fractures of The Body of The Mandible In Maxillofacial Surgery

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